Tuesday, April 30, 2013

On a stormy evening this spring, nurses at Dr. Gary Stuck’s family practice were on the phone with patients with heart ailments, asking them not to shovel snow. The idea was to keep them out of the hospital, and that effort — combined with dozens more like it — is starting to make a difference: across the city, doctors are providing less, but not worse, health care.

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

This approach is one small part of a growing effort by providers to hold down costs without restricting needed care. Nationwide, health care spending has grown over the last three years at the slowest rate since the federal government started keeping data more than 50 years ago. While the bulk of that is related to the poor economy, changes among insurers and health care providers have contributed as well. If the trend continues, even at a reduced pace, it could help alleviate Washington’s long-term deficit problems and ease the strain on family budgets.

By Norimitsu OnishiThe New York Times
Originally published April 5, 2013

A federal judge on Friday rejected California’s motion to regain control of mental health care in its prisons, ruling that the quality of care failed to meet standards required by the Constitution. The move dealt a blow to Gov. Jerry Brown’s broader efforts to bring the prisons back under the state’s authority.

In a ruling handed down about 90 days after the state first argued that enough improvements had been made to mental health care after 18 years of outside control, Judge Lawrence K. Karlton of United States District Court in Sacramento wrote that there were “ongoing constitutional violations” and that court oversight “remains necessary to remedy those violations.”

In a statement, Deborah Hoffman, a spokeswoman for the California Department of Corrections and Rehabilitation, said that the judge had not given enough weight to experts and evidence showing that mental health care in the prisons was “a model for the nation.” She said that the state will appeal.

Sunday, April 28, 2013

A new study shows that neither criminal background checks nor pre-admission
screening questions accurately predict students likely to commit crime on
college campuses.

"In an effort to reduce campus crime, more than half of all American colleges
ask applicants about their criminal histories or require criminal background
checks," said study author Carol Runyan , Ph.D., MPH, and professor of
epidemiology at the Colorado School of Public Health. "But there is no real
evidence to show this reduces campus crime."

Colleges across the U.S. ramped up background checks after the 2007 Virginia
Tech massacre which killed 32 people and wounded another 17.

Yet Runyan found that only 3.3 percent of college seniors who engaged in
misconduct actually reported precollege criminal histories during the admissions
process. And just 8.5 percent of applicants with a criminal history were charged
with misconduct during college.

The study surveyed 6,972 students at a large southern university. It found
that students with criminal records prior to college were more likely to commit
crimes once admitted but the screening process rarely identified them.

"We didn't look at cheating or minor alcohol offences," Runyan said. "We
focused on significant offences like assault, robbery, property crimes, driving
under the influence of alcohol, marijuana use and other drug-related
crimes."

While colleges are generally safe environments, students can be both
perpetrators and victims of crimes that pose risks to the entire campus
community, Runyan said.

She noted that earlier studies had reported that up to 14 percent of all
college men admitted to some kind of sexual assault or coercion while 30 percent
of university males and 22 percent of females said they had driven under the
influence of alcohol in the last year. Also, 19 percent of students reported
illicit drug use.

Runyan's findings indicate that students who engage in criminal activity
during college are more likely to have engaged in misconduct prior to college,
whether they admit it on their applications or not. However, she said current
screening questions on the college application often fail to detect which
students will engage in misconduct during college. And most of those who have
records before college don't seem to continue the behaviors in college.

Even if the screenings could identify likely troublemakers, Runyan said,
colleges would have to decide whether to admit the students given that the odds
of them committing a crime on campus would still be low. And much of the
reported precollege crime involves marijuana use and is not violent.

Another complication is possible discrimination. Students from more affluent
backgrounds, who tend to be white, can often pay to have their early criminal
records expunged while others, including many minorities, can't afford it.

"Based on our work, I cannot say with confidence that colleges should stop
asking about criminal backgrounds, but I would use caution in thinking that this
is the best strategy to address crime on campus," said Runyan who directs the
University of Colorado's Pediatric Injury Prevention, Education and Research
Program. "We need to ensure a safe and supportive environment for all students
rather than limiting college access for students who may need extra help."

The study was recently published in the journal Injury Prevention and
will be presented by Runyan at a conference in June.

Saturday, April 27, 2013

Lawmakers voted 77 to 44 in favour of the gay-marriage bill on its third and final reading.
People watching from the public gallery and some lawmakers immediately broke into song after the result was announced, singing the New Zealand love song Pokarekare Ana in the indigenous Maori language.

"For us, we can now feel equal to everyone else," said Tania Penafiel Bermudez, a bank teller who said she already considers herself married to partner Sonja Fry but now can get a certificate to prove it. "This means we can feel safe and fair and right in calling each other wife and wife."

Searching for compromise on a divisive issue, the Boy Scouts of America is proposing to partially lift its long-standing exclusion of gays — allowing them as youth members but continuing to bar them as adult leaders.

The proposal, unveiled Friday after weeks of private leadership deliberations, will be submitted to the roughly 1,400 voting members of the BSA's National Council during the week of May 20 at a meeting in Texas.

The key part of the resolution says no youth may be denied membership in the Scouts "on the basis of sexual orientation or preference alone." A ban would continue on leadership roles for adults who are openly gay or lesbian.

Gay-rights groups, which had demanded a complete lifting of the ban, criticized the proposal as inadequate.

"Until every parent and young person have the same opportunity to serve, the Boy Scouts will continue to see a decline in both membership and donations," said Rich Ferraro, a spokesman for the gay-rights watchdog group GLAAD.

Chad Griffin, president of the Human Rights Campaign, said the BSA was too timid.

Friday, April 26, 2013

Policy Statement From the American College of Physicians and the Federation of State Medical Boards

Ann Intern Med. 16 April 2013;158(8):620-627

Abstract

User-created content and communications on Web-based applications, such as networking sites, media sharing sites, or blog platforms, have dramatically increased in popularity over the past several years, but there has been little policy or guidance on the best practices to inform standards for the professional conduct of physicians in the digital environment. Areas of specific concern include the use of such media for nonclinical purposes, implications for confidentiality, the use of social media in patient education, and how all of this affects the public's trust in physicians as patient–physician interactions extend into the digital environment. Opportunities afforded by online applications represent a new frontier in medicine as physicians and patients become more connected. This position paper from the American College of Physicians and the Federation of State Medical Boards examines and provides recommendations about the influence of social media on the patient–physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician–physician communication that preserve confidentiality while best using these technologies. Because of the creation and use of information online and the widespread use of the Internet and Web 2.0 platforms, physicians and others are increasingly required to consider how best to protect patient interests and apply principles of professionalism to new settings. As new technologies and practices, such as social networking, are embraced, it is paramount to maintain the privacy and confidentiality of patient information, demonstrate respect for patients, ensure trust in physicians and in the medical profession, and establish appropriate boundaries. To protect patients and the public and promote quality health care, it is critical to strike the proper balance to harness opportunities while being aware of inherent challenges in using technology. But as others have pointed out, “Connectivity need not come at the expense of professionalism”.

Organizational statements addressing these issues are starting to appear, but they may not provide specific guidance to deal with and anticipate concerns. Innovations often bring benefits, but rapid introduction of technology sometimes outpaces existing policies, laws, and guidelines. This article provides a framework for analyzing medical ethics and professionalism issues in online postings and interactions, including the use of electronic resources for clinical or direct patient care involving patient information outside of the electronic health record, and the nonclinical or personal use of these media. It presents the implications of online activities for patients, physicians, the profession, and society and contains recommendations that address online communication with patients, the use of social media sites to gather and share information about patients, physician-produced blogs, physician posting of personal information that patients can access, and communications among colleagues about patient care.

Thursday, April 25, 2013

Over the past five years, Nevada's primary state psychiatric hospital has put hundreds of mentally ill patients on Greyhound buses and sent them to cities and towns across America.

Since July 2008, Rawson-Neal Psychiatric Hospital in Las Vegas has transported more than 1,500 patients to other cities via Greyhound bus, sending at least one person to every state in the continental United States, according to a Bee review of bus receipts kept by Nevada's mental health division.

About a third of those patients were dispatched to California, including more than 200 to Los Angeles County, about 70 to San Diego County and 19 to the city of Sacramento.

In recent years, as Nevada has slashed funding for mental health services, the number of mentally ill patients being bused out of southern Nevada has steadily risen, growing 66 percent from 2009 to 2012. During that same period, the hospital has dispersed those patients to an ever-increasing number of states.

(cut)

It also is cheaper, he noted. Southern Nevada Adult Mental Health Services spent a total of $205,000 putting patients on Greyhound buses during the past five years, according to The Bee analysis. The state hospital admits about 4,000 patients a year to its inpatient unit, and inpatient care runs around $500 per day per client, Ghertner said.

Wednesday, April 24, 2013

By Ted GupThe New York Times Op-Ed
Originally published on April 2, 2013

Here are some excerpts:

No one made him take the heroin and alcohol, and yet I cannot help but hold myself and others to account. I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

My son was no angel (though he was to us) and he was known to trade in Adderall, to create a submarket in the drug among his classmates who were themselves all too eager to get their hands on it. What he did cannot be excused, but it should be understood. What he did was to create a market that perfectly mirrored the society in which he grew up, a culture where Big Pharma itself prospers from the off-label uses of drugs, often not tested in children and not approved for the many uses to which they are put.

And so a generation of students, raised in an environment that encourages medication, are emulating the professionals by using drugs in the classroom as performance enhancers.

And we wonder why it is that they use drugs with such abandon. As all parents learn — at times to their chagrin — our children go to school not only in the classroom but also at home, and the culture they construct for themselves as teenagers and young adults is but a tiny village imitating that to which they were introduced as children.

The issue of permissive drug use and over-diagnosis goes well beyond hyperactivity. In May, the American Psychiatric Association will publish its D.S.M. 5, the Diagnostic and Statistical Manual of Mental Disorders. It is called the bible of the profession. Its latest iteration, like those before, is not merely a window on the profession but on the culture it serves, both reflecting and shaping societal norms. (For instance, until the 1970s, it categorized homosexuality as a mental illness.)

By Allie GrasgreenInside Higher Ed
Originally published April 12, 2013

The findings of this year’s survey of college counseling directors about the state of their students and the centers where they treat them look a whole lot like last year’s (in some ways good, in some ways bad).

The percentage of students seeking help for various problems continues to creep up in many areas, and nearly all respondents to the Association for University and College Counseling Center Directors’ annual survey said the number of students with “significant psychological problems” is a growing concern for them. Also still on the slow but (mostly) steady rise are counseling centers’ budgets and staffing levels.

Four hundred directors -- about half the association’s membership -- completed the survey during the 2011-12 academic year. Together, they account for 319,634 students who sought mental health services during that time. The colleges are about split between public and private, mostly four-year, and vary in size and location.

About two-thirds of directors also said they perceived an increase last year in the number of students coming in with “severe psychological problems” (21 percent of students overall) and already taking psychotropic medications (24 percent of students).

Directors also, as has been the case in the past, are unsure whether those students’ needs are being met. About six in 10 directors have psychological services available on their campuses, but 19 percent say what’s available is inadequate.

Tuesday, April 23, 2013

By Sabrina TaverniseThe New York Times
Originally published on April 10, 2013

A federal agency has found that a number of prestigious universities failed to tell more than a thousand families in a government-financed study of oxygen levels for extremely premature babies that the risks could include increased chances of blindness or death.

None of the families have yet been notified of the findings from the Office for Human Research Protections, which safeguards people who participate in government-financed research. But the agency’s conclusions were listed in great detail in a letter last month to the University of Alabama at Birmingham, the lead site in the study. In all, 23 academic institutions took part, including Stanford, Duke and Yale.

The letter stated that the study did have an effect on which infants died and which developed blindness, and that those risks were not properly communicated to the parents, depriving them of information needed to decide whether to participate.

A group of academics from Oxford, Stanford, Virginia and Bristol universities have looked at a range of subfields of neuroscience and concluded that most of the results are statistically worthless.

The researchers found that most structural and volumetric MRI studies are very small and have minimal power to detect differences between compared groups (for example, healthy people versus those with mental health diseases). Their paper also stated that, specifically, a clear excess of "significance bias" (too many results deemed statistically significant) has been demonstrated in studies of brain volume abnormalities, and similar problems appear to exist in fMRI studies of the blood-oxygen-level-dependent response.

The team, researchers at Stanford Medical School, Virginia, Bristol and the Human Genetics dept at Oxford, looked at 246 neuroscience articles published in 2011 and and excluded papers where the test data was unavailable. They found that the papers' median statistical power - the possibility that a study will identify an effect when there is an effect there to be found - was just 21 per cent. What that means in practice is that if you were to run one of the experiments five times, you’d only find the effect once.

A further survey of papers drawn from fMRI brain scanners - and studies using such scanners have long filled the popular media with dramatic claims - found that their statistical power was just 8 per cent.

Monday, April 22, 2013

Accreditation by U.S. agencies is a prize that many universities in the Arab world have sought in recent years, a prize that allows them to sell students from the region on getting an education at U. S. standards closer to home and at a lower cost.

But could that prize have a price—the risk of losing accreditation if autocratic Arab regimes tighten up, academic freedom slips, and accreditation gets pulled?

Accreditation in the United States is carried out by agencies responsible for different regions of the country, some of which have recently ventured overseas to accredit foreign universities. All of the U.S. accreditation agencies have at least some academic freedom guidelines. “The success of American higher education, including the high regard in which it is held worldwide, is explained in good measure by the observance of academic freedom,” said an October 2012 statement of the American Association of University Professors and the Council for Higher Education Accreditation.

A recent incident in the United Arab Emirates put that emphasis on academic freedom into focus. A conference co-organized by the London School of Economics and the American University of Sharjah was set to be held in the Emirates in February, then cancelled after the government insisted that a presentation about Bahrain be dropped. The London School of Economics called off the conference “in response to restrictions imposed on the intellectual content of the event that threatened academic freedom.”

By Larry Hirschhorn
Learning from Experience Blog
Originally published on April 12, 2013

This past week Rutgers University fired its basketball coach, Mike Rice, and pressured its athletic director to resign. For our European colleagues, Rutgers is the major public university in the state of New Jersey. An assistant basketball coach for the university’s basketball team, Erick Murdock, unhappy over what he described as his dismissal ten months ago, created video footage of Coach Rice hitting players during practice and calling them “faggots” and “homos.” ESPN got hold of the video, most likely from Murdock’s lawyer, and the university, upon learning that ESPN was about to file a report, released the video to the public. The video created a public relations scandal leading to Rice’s firing and the athletic director’s resignation. Some faculty members asked that the University's president, Robert Barchi, resign. Readers interested in seeing an extract from the video can go here.

The press focused on the video and the coach’s distasteful if not abusive behavior. But journalists paid little to attention to a report the university’s outside counsel wrote several months before the video’s release. The report, conveys a much more nuanced picture of Rice’s behavior and its meaning. In the popular press Murdock was a whistle blower who was fired after he complained about the Coach’s abusive behavior. But nothing could be farther from the truth. This gap sheds important light on the challenges we face in situating information in its appropriate context. In fact, this case suggests that the "information revolution" strips information from its context. This is why executives can no longer control the public narrative about the institutions they lead. Their leadership is jeopardized.

Let’s consider four features of the popular narrative about Coach Rice’s behavior. My goal is to not defend or condemn his behavior. Instead, I want to show that when we consider the context of a seemingly straightforward narrative, -- a whistle blowing hero brings down a villain-- its simplicity and evident standing as a morality tale is undermined. We have to ask, “What is real?” Below, I introduce each section of my analysis by first italicizing the feature of the narrative I propose to examine.

Sunday, April 21, 2013

A $3 million grant from Google helped get an anti-human-trafficking hotline up and running today — the latest data-sharing effort aimed at fighting the growing problem.

The Global Human Trafficking Hotline Network, launched with Google's grant, will allow organizations working in the USA, Southeast Asia and Europe to standardize data, identify trends and combine statistics for a more comprehensive look at the issue.

"Right now, most of the hotlines around the world are doing great work but operating in isolation," said Bradley Myles, CEO of Polaris Project, a non-profit group that runs the U.S. human trafficking hotline. "The fight has to be more thoughtful, so collaboration and partnerships in this field can keep up and get ahead of the innovation of traffickers."

Polaris Project, Liberty Asia, a non-profit group that does work in Southeast Asia, and La Strada International, which focuses on parts of Europe, have been jointly awarded a Google Global Impact Award and will work to stitch together their different hotlines.

MORAL quandaries often pit concerns about principles against concerns about practical consequences. Should we ban assault rifles and large sodas, restricting people’s liberties for the sake of physical health and safety? Should we allow drone killings or torture, if violating one person’s rights could save a thousand lives?

We like to believe that the principled side of the equation is rooted in deep, reasoned conviction. But a growing wealth of research shows that those values often prove to be finicky, inconsistent intuitions, swayed by ethically irrelevant factors. What you say now you might disagree with in five minutes. And such wavering has implications for both public policy and our personal lives.

Philosophers and psychologists often distinguish between two ethical frameworks. A utilitarian perspective evaluates an action purely by its consequences. If it does good, it’s good.

Saturday, April 20, 2013

Patients, their families, and physicians have been satisfied with a "death with dignity" physician-assisted suicide program made available to terminal cancer patients at a Seattle clinic, clinicians there reported.

Among 114 patients who asked about the program at the Seattle Cancer Care Alliance, the outpatient clinic for the city's major cancer treatment centers, 40 passed screening examinations and ultimately received lethal prescriptions for secobarbital, although only 24 actually took the drug, according to Elizabeth Trice Loggers, MD, PhD, and colleagues at the clinic and its affiliated centers.

"Patients, caregivers, and family members have frequently expressed gratitude after the patient obtained the prescription, regardless of whether it was ever filled or ingested, typically referencing an important sense of control in an uncertain situation," the authors wrote in the April 11 issue of the New England Journal of Medicine.

By Serena Gordon
HealthDay Reporter
Originally published April 10, 2013
Physician-assisted suicide laws can raise controversy and concern with their passage, but a new study from Washington state suggests many of those fears may be unfounded.

Washington's Death With Dignity Act hasn't lead to scores of terminally ill people seeking lethal prescriptions, the researchers report: Almost three years after the law was enacted, just 255 people had obtained a lethal prescription from a physician.

Of those 255 prescriptions, 40 were written for terminal cancer patients at the Seattle Cancer Care Alliance. And, in the new study, doctors there found that only 60 percent (24 people) of their patients chose to use their prescription to hasten their death.

"Most Americans say that they want to die at home with family members around, not in pain and with their mental faculties as in tact as possible. But, not everyone is achieving that kind of good death. For the rare number of people using the Death With Dignity program, we are reassured by the high numbers of people who use palliative or hospice care and who talk with their families about this decision," said study author Dr. Elizabeth Trice Loggers, medical director of palliative care at the Seattle Cancer Care Alliance.

Friday, April 19, 2013

Andrew Wakefield's 'dishonest and irresponsible' research into the causes of autism led to his being struck off by the General Medical Council. That would have ended most doctors' careers. Instead, the MMR 'martyr' moved to the US – and into reality TV

By Alex HannafordThe Guardian
Originally published April 5, 2013

For three days at the end of January, the Renaissance hotel in Washington DC fills up with television executives from around the world. The Realscreen Summit is where the makers of reality TV gather to discuss ideas, negotiate deals and discover the next Apprentice or I'm A Celebrity. Among the estimated 2,200 people who had paid up to $1,600 (£1,050) this year to try to snag face time with an exec from Freemantle, TLC, Discovery or National Geographic was an Englishman in his mid-50s wearing jeans, a crisp, white shirt and loafers, and carrying a MacBook. On his badge were the words "Autism Team".

This man's pitch was a reality TV series about autism, and he had a short trailer on his laptop: an autistic child screams; another bites his mother's hand; another repeatedly and violently slams a book against his head. Then a narrator tells us that "every day across the world, medical symptoms of hundreds of thousands of people with autism are being ignored". Cue piano music and the titles, The Autism Team: Changing Lives.

The premise is that the autism symptoms suffered by the children in the promo (Jon, 14, who is "wasting away"; six-year-old twins "still not potty trained"; and 15-year-old Jack, who is "non-verbal and very self-injurious") have left their parents feeling helpless and alone — until, that is, the Autism Team steps in to save the day.

The scientists who were recruited to appear at a conference called Entomology-2013 thought they had been selected to make a presentation to the leading professional association of scientists who study insects.

But they found out the hard way that they were wrong. The prestigious, academically sanctioned conference they had in mind has a slightly different name: Entomology 2013 (without the hyphen). The one they had signed up for featured speakers who were recruited by e-mail, not vetted by leading academics. Those who agreed to appear were later charged a hefty fee for the privilege, and pretty much anyone who paid got a spot on the podium that could be used to pad a résumé.

“I think we were duped,” one of the scientists wrote in an e-mail to the Entomological Society.

Those scientists had stumbled into a parallel world of pseudo-academia, complete with prestigiously titled conferences and journals that sponsor them. Many of the journals and meetings have names that are nearly identical to those of established, well-known publications and events.

Steven Goodman, a dean and professor of medicine at Stanford and the editor of the journal Clinical Trials, which has its own imitators, called this phenomenon “the dark side of open access,” the movement to make scholarly publications freely available.

Thursday, April 18, 2013

By Richard FriedmanThe New York Times - Opinion
Originally published April 6, 2013

LAST year, more active-duty soldiers committed suicide than died in battle. This fact has been reported so often that it has almost lost its jolting force. Almost.

Worse, according to data not reported on until now, the military evidently responded to stress that afflicts soldiers in Iraq and Afghanistan primarily by drugging soldiers on the front lines. Data that I have obtained directly from Tricare Management Activity, the division of the Department of Defense that manages health care services for the military, shows that there has been a giant, 682 percent increase in the number of psychoactive drugs — antipsychotics, sedatives, stimulants and mood stabilizers — prescribed to our troops between 2005 and 2011. That’s right. A nearly 700 percent increase — despite a steady reduction in combat troop levels since 2008.

The prescribing trends suggest that the military often uses medications in ways that are not approved by the Food and Drug Administration and do not comport with the usual psychiatric standards of practice.

The military tests prospective enlistees with an eye toward screening out those with serious psychiatric disorders. So you would expect that the use of these drugs in the military would be minimal — and certainly less than in the civilian population. But the opposite is true: prescriptions written for antipsychotic drugs for active-duty troops increased 1,083 percent from 2005 to 2011; the number of antipsychotic drug prescriptions in the civilian population increased just 22 percent from 2005 to 2011, according to IMS Health, an independent medical data company.

By Anahad O'ConnorThe New York Times - Well Column
Originally published April 15, 2013

Doctors in the United States routinely prescribe potentially harmful drugs to older patients, and the problem is particularly acute in the South, a new study shows.

The analysis found that more than one in five seniors on Medicare in the South were prescribed medications that health authorities have specifically advised doctors to avoid giving to older patients because of their severe side effects. Compared with people 65 and older living in New England, those living in the southern region from Texas to South Carolina were about 12 percent more likely to be prescribed a high-risk medication.

The researchers suspected that factors like education, socioeconomic status and access to quality medical care might be driving some of the regional differences. And to some extent, that appeared to be the case. As socioeconomic status grew lower, for example, the likelihood of being prescribed a high-risk drug increased. But even after accounting for these factors, the researchers found that the disparity persisted.

You’d be forgiven if, after reading last month’s Health Affairs, you came to the conclusion that all manner of wellness programs simply will not work; in it, a spate of articles documented myriad failures to make patients healthier, save money, or both.

Which is a shame, because – let’s face it – we need wellness programs to work and, in theory, they should. So I’d rather we figure out how to make wellness work. It seems that a combination of behavioral economics, technology, and networking theory provide a framework for creating, implementing, and sustaining programs to do just that.

Let’s define what we’re talking about. “Wellness program” is an umbrella term for a wide variety of initiatives – from paying for smoking cessation, to smartphone apps to track how much you walk or how well you comply with your plan of care, and everything in between. The term is almost too broad to be useful, but let’s go with it for now.

When we say “Wellness programs don’t work,” the word work does a lot of, well, work. If a wellness program makes people healthier but doesn’t save lives, is it “working”? What if it saves money but doesn’t make people healthier?

To be thorough and appropriately critical, let’s go with the following definition: a wellness program “works” if it improves the health of a population and reduces health care costs for that population. Full stop.

Tuesday, April 16, 2013

Every psychologist must read and know the basic tenets of the American Psychological Association’s Code of Ethics in order to get through graduate school and obtain a license to practice psychology.We’ve all read it.We’ve all learned it.We’ve all tried to apply it.How many of us have asked the question, “Why bother?”Obviously, the entire concept of ethical behavior is rooted in our system of morality and, although the word “should” often has a negative connotation in our psychotherapeutic lexicon, any ethics code is all about what we should and should not do.Codes attempt to answer the question, “What’s the right thing to do in this situation?”

It’s interesting to me that nowhere in the current Ethics Code is this question directly addressed.The issue is addressed only obliquely.The Preamble states,

“Psychologists are committed to increasing scientific and professional knowledge of behavior and people’s understanding of themselves and others and to the use of such knowledge to improve the condition of individuals, organizations, and society.Psychologists respect and protect civil and human rights and the central importance of freedom of inquiry and expression in research, teaching, and publication.They strive to help the public in developing informed judgments and choices concerning human behavior.In doing so, they perform many roles, such as researcher, educator, diagnostician, therapist, supervisor, consultant, administrator, social interventionist, and expert witness.This Ethics Code provides a common set of principles and standards upon which psychologists build their professional and scientific work.”

It seems to me, what the preamble does is one thing.It advises us that this code of shoulds and should nots is intended to guide our behavior to facilitate our work as psychologists.Essentially, the Ethics Code advises us that we’ll do a better job of being psychologists if we follow the principles articulated there in.It helps us do our work.

What is our work?The jobs that psychologists do could fill a book, in fact, they fill many books.But for most of the membership of this state psychological association, our work consists largely of psychological assessment and psychotherapy.It’s important work.

This Christmas, I was reminded of the importance of the work we do via a Christmas card I received from one of my former patients.Here’s the story.Almost three decades ago, I was asked to evaluate a family because one of the parents had been found guilty of abusing a child.In response to a child’s episode of enuresis, the parent placed the child in a bathtub full of ice cubes and cold water for half an hour.The community’s response was to place all three children in foster care.When I was asked to evaluate the family, I administered a variety of psychological tests to the entire family.

Through the assessment process, I uncovered important information as I worked with this very poor, rural family. The parents had graduated from high school as Special Education students, with Wechsler IQs near the bottom of the borderline range.But they also had near perfect handwriting and spelling on the Rotter and WRAT and that told me they were capable of learning.The father worked as a laborer and the mother, while somewhat disabled, worked as a homemaker caring for her family.While talking with the parents during interviews, I found them to be loving, devoted people.I learned that they had treated the enuresis problem using the same disciplinary technique used on them when they were children.In their minds, they weren’t being abusive; they were being good parents.I established a good relationship with them during the evaluation and ultimately worked with them in family therapy, which largely consisted of psycho-education – I had them read Dr. Spock’s Baby and Child Care and then we discussed it, section by section.We worked hard.These two parents eventually got their kids back and raised them as well as they could given the limits of their intellect, education, and finances.What would you expect to be the outcome?Here’s what was in their annual Christmas card to me this year.Obviously, the information has been disguised to protect identities.However, the original punctuation is maintained.

“Our son, Tim, is in Columbus going through college at Ohio State, business engineering, our daughter Martha is going through college at Indiana University in Indiana, criminal justice she wants to be a detective and she also works at the grocery store.Our youngest moved to Erie, PA, in July she works at a Walgreen pharmacy.John and I are just fine.Hope all is fine and well where you are.Take care….”

We all have cases like this in our files, don't we?We do very important work out there and sometimes we forget that reality.

There were a number of significant ethical issues in this case.For example, all the potential dangers regarding multiple relationships needed to be navigated.Clarifying the identity of my client or clients at various points was a challenge.I didn’t always adhere to the letter of the then current Ethics Code, but I certainly tried to adhere to the spirit of the document.It helped me to do what I think was good work.I think our system of ethics helps us all to do good work.And, I think that’s why we have an Ethics Code and why we should behave ethically.Maybe you’ve got a better reason, but that’s the best answer I can come up with.It helps us do good work. And that’s why we’re here, isn’t it?

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist,Vol. 57, 1060-1073.

If you have specific suggestions for topics to be covered in The Ethics Corner, please e-mail me with your suggestions.My e-mail address is ragusea@aol.com.

Ethics is about who we are. Ethics is not so much about what is happening around us, it’s much more about what is going on inside of us. Understanding the difference is critical to being a person with good ethics. Ethics are not concerned about what we can do, but what we should do. Ethics align us to our purpose and our values no matter what is happening around us.

Ethics are about how we will measure our life. Our choices are taking us somewhere. The question is, “Where do we want to end up and what kind of person do we want to be when we get there?”

Monday, April 15, 2013

Dr. Solomon, a psychologist on an inpatient psychiatric treatment team, is concerned about the pending discharge of a current inpatient. The patient admitted herself to the unit, with some persuasion by the local police, for making loud threats and menacing gestures in her neighbor’s driveway. Hence, the admission is voluntary.

Currently, the patient is denying the fact that she has made past threats toward her neighbor. However, the police report indicated she has made such verbal threats in the past but also, on several occasions, has damaged her neighbors property including scratching the paint on their car and throwing rocks at their house. Innuendos are that she allegedly killed her neighbors pet, but this has been unproven by the police.

During some individual time, the patient indicated to the psychologist that she has “had it” with her neighbor and has “something planned that will make you all finally understand” once she is discharged.

While the treatment team does not share Dr. Solomon’s concern and has started to make discharge plans, they have not spent as much individual time with the patient as Dr. Solomon. In fact, the patient has made no such comments to anyone else other than to Dr. Solomon and has been a model patient on the unit. The days allocated for her stay by her insurance are ending in two days. The attending psychiatrist concurs with the discharge plan and advised Dr. Solomon “not to worry about it.” In fact, the psychiatrist encouraged the psychologist to omit any reference to the patient’s comments about the neighbor in treatment summaries or clinical notes as “hysterical nonsense.”

Sunday, April 14, 2013

He has been famously portrayed as a bore, a man whose habits were so regular that housewives could set their watches by his legendary afternoon walk.

But according to three new biographies, the celebrated German philosopher Immanuel Kant was not such a dry stick after all. Far from being a dour Prussian ascetic, the great metaphysician was a partygoer. He enjoyed drinking wine, playing billiards and wearing fine, colourful clothes.

He had a sense of humour, and there were women in his life, although he never married. On occasion, Kant drank so much red wine he was unable to find his way home, the books claim.

The biographies - which shed fresh light on the party-loving behaviour of the young Kant before his fame - have appeared in Germany ahead of the 200th anniversary of his death today.

They also coincide with a visit by Germany's foreign minister, Joschka Fischer, to Kaliningrad - the Russian Baltic port where Kant spent all his life when it was Königsberg, in what was then East Prussia.

Mr. Fischer set off from Berlin yesterday and took several German philosophers with him. He is expected to lead the Kant anniversary celebrations today by laying a wreath on the philosopher's memorial and will open a German consulate in the city.

Saturday, April 13, 2013

Throughout his adult life, Mr. Tarloff, 45, has been prescribed antipsychotic medication to alleviate delusions and hallucinations. He has received a diagnosis of schizophrenia and been hospitalized against his will numerous times. And three months after one such commitment, Mr. Tarloff entered an Upper East Side medical office on Feb. 12, 2008, and killed Kathryn Faughey, a psychologist, with a mallet and a knife.

Yet a lifetime of being crazy hardly makes an insanity defense a sure thing. Mr. Tarloff’s lawyers must convince jurors, who will begin deliberations Wednesday, that he was so sick that day that he did not understand the consequences of his actions: that pounding and stabbing Dr. Faughey could kill her, or that the attack was wrong.

The standard is so difficult to meet that few defendants using the insanity defense in New York win at trial. Of 5,910 murder cases completed in the last decade statewide, only seven defendants have been found at trial to be not responsible by reason of mental disease or defect, according to the state Division of Criminal Justice Services.

The state does not track how often the defense is raised. But failed attempts at the insanity defense regularly receive public attention, including Andrew Goldstein, a schizophrenic who in 1999 pushed Kendra Webdale to her death in front of a subway train, and Renato Seabra, a Portuguese fashion model who in 2011 murdered and mutilated his lover in a Times Square hotel. Both were found criminally responsible for murder.

Residents of states with the highest rates of gun ownership and political conservatism are at greater risk of suicide than those in states with less gun ownership and less politically conservative leanings, according to a study by University of California, Riverside sociology professor Augustine J. Kposowa.

The study, "Association of suicide rates, gun ownership, conservatism and individual suicide risk," was published online in the journal Social Psychiatry & Psychiatric Epidemiology in February.

Suicide was the 11th leading cause of death for all ages in the United States in 2007, the most recent year for which complete mortality data was available at the time of the study. It was the seventh leading cause of death for males and the 15th leading cause of death for females. Firearms are the most commonly used method of suicide by males and poisoning the most common among females.

Kposowa, who has studied suicide and its causes for two decades, analyzed mortality data from the U.S. Multiple Cause of Death Files for 2000 through 2004 and combined individual-level data with state-level information.

Friday, April 12, 2013

By Bradley CorneliusInside Higher Ed: The Academic Minute
Originally published April 1, 2013

Dr. Sam Sommers – Context and Moral Behavior

Context matters. This may not sound like a profound conclusion, but behavioral science reveals that it’s one we often overlook in pondering human nature. We hear the news about the latest fraud case or the crowd that stood idly by with an emergency going on right in front of it, and we chalk up the events to bad apples—simply people with poor personalities behaving poorly.

But this worldview oversimplifies. How do we most accurately predict whether individuals will rise to the occasion in an emergency? By examining the specifics of the situation. In a famous study at Princeton, seminary students had to walk across campus to give a talk on an assigned topic. Researchers arranged for students to pass by a shabbily dressed actor stooped over and coughing in a doorway. Fewer than half stopped to help, in some instances literally stepping over a man in apparent need on their way to discuss the parable of the Good Samaritan. Personality differences weren’t the best predictors of their behavior. Rather, the simple matter of whether or not they were running late was most influential.

This hidden power of situations has far-reaching implications. We’re more influenced by the actions of those around us than we’d like to believe. Even our private sense of identity is highly context-dependent. Or consider research in my lab on the observable effects of a group’s diversity on its performance. How does diversity influence groups? It depends. Create a situation in which people are primarily focused on making a good impression and their anxiety tends to undermine communication and social skills. Tell them instead to focus on maximizing task performance and not only does performance improve, but people also wind up getting along better. In short, human nature is far more malleable and context-dependent than we assume it is.

Michael Boucai, Sexual Liberty and Same-Sex Marriage: An Argument from Bisexuality, 49 San Diego L. Rev. 415 (2012), available at The Williams Institute.

By Clifford RoskyFamily Law: JOTWELL
Originally posted March 27, 2013

For more than twenty years, the constitutionality of laws against same-sex marriage has remained a hot topic among scholars, lawyers, and judges in the United States. This month, the U.S. Supreme Court will finally hear argument on the constitutionality of two such laws—the federal law known as the Defense of Marriage Act and an amendment to the California Constitution known as Proposition 8.

After so many years and so many challenges, it has become increasingly difficult to find arguments and angles on this topic that are genuinely novel. In recent years, it often feels as if the question has been exhausted—as if both sides have already said what is worth saying, and we all are just repeating ourselves, pleading and praying for Justice Kennedy’s vote.

Yet in his recent article, Professor Michael Boucai (Buffalo) manages to stake out a powerful new claim for same-sex marriage—a claim based on homosexual liberty, rather than the equality of lesbian and gay people or the fundamentality of marriage itself. In the article’s opening sentence, Boucai explains: “This Article proposes that same-sex marriage bans channel individuals, particularly bisexuals, into heterosexual relations and relationships, impermissibly burdening the sexual liberty interest protected under Lawrence v. Texas.”

As Boucai recognizes, his argument from sexual liberty “departs dramatically” from the paradigms of advocacy and scholarship on this subject.

Thursday, April 11, 2013

By LAWRENCE K. ALTMAN, M.D.The New York Times
Published: April 1, 2013

Medicine honors its heroes in many ways. But sometimes high accolades can turn out to be highly embarrassing.

Consider the annual award for lifetime achievement in preventing and controlling sexual infections, given since 1972 by the American Sexually Transmitted Diseases Association. The prize is named for an authentic giant of medicine: Dr. Thomas Parran Jr., the nation’s sixth surgeon general (from 1936 to 1948), who used what was then a supremely powerful position to lift American public health to the front ranks.

At a time when “venereal diseases” were spoken of in whispers, Dr. Parran influenced Congress to finance rapid-treatment centers to control and prevent syphilis, gonorrhea and chancroid.

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The debate over the Parran Award throws a spotlight on the issue of changing standards in medicine. What are scientists to do when they name their most prestigious award for an icon linked years later to unethical research?

The two medical scandals revolved around experiments that are now universally regarded as shocking. Dr. Parran did not perform either study. Though national experts approved them both, he presided over them, strongly supported them and followed their progress in medical journals.

One, the Tuskegee study, observed the course of untreated syphilis among hundreds of men who were infected naturally in Alabama. The study began in 1932, and it was not halted by the United States Public Health Service until 1972, after a whistle-blower complained that infected patients in the study were not given penicillin, the standard therapy after World War II. Some participants died of the disease, some of their sexual partners contracted it, and some children were born infected.

Editor's Note: I enjoyed reading and trying to understand Lacan. Here is a portion about Lacan, ethics, professional history, and group behavior.

The 1960s were a highly productive and equally tumultuous era in Lacan's history. In his seventh seminar on The Ethics of Psychoanalysis (1959–1960), Lacan took a sort of turn fateful for the direction of his later trajectory, initiating an interrogation of the ways in which language was privileged by his 1950s “return to Freud.” The immediately prior years tirelessly emphasized the essential role of the register of the Symbolic, namely, the pride of place of analytically modified versions of Saussurian signifiers in the structures and dynamics of the unconscious and speaking subjectivity (in the 1930s and 1940s, the phenomenal-visual register of the Imaginary was to the fore thanks to the focus on the mirror stage). At the end of the 1950s, with the rise of the Real as the register of a new focus of Lacan's thinking—I will say more about Lacan's tripartite register theory subsequently (see 2.1 below)—things and phenomena escaping, resisting, or thwarting the signifying powers of the socio-linguistic symbolic order became ever more central in Lacanian theory. These things and phenomena include Otherness, drives, jouissance, and objet petit a, among other Lacanian concepts (see 2.3, 2.4.2, and 2.4.3 below). This 1959–1960 seminar defensibly can be depicted as a prescient post-structuralist text avant la lettre.

An earthquake in Lacan's professional and personal histories hit him in 1963. For ten years (1953–1963), the SFP, following its creation after the defections from the SPP, was being scrutinized at length by the IPA as a training institute applying for IPA membership. To cut a long story short, the IPA ended up offering the SFP an ultimatum: It could be admitted only if Lacan was struck from its list of training analysts. Lacan's non-standard “variable-length sessions,” deviating from the fixed-length session rules of IPA orthodoxy, was the main reason for the IPA's withholding of its recognition from him. The SFP accepted this condition, stripping Lacan of his standing within it. In the aftermath of what he understandably experienced as a deeply wounding betrayal, he abandoned his original plans for a 1963–1964 seminar on The Names-of-the-Father (only its opening session of November 20, 1963 was given), relocated his teaching from the Hôpital Sainte-Anne to the École Normale Supérieure, and conducted his deservedly renowned eleventh seminar of 1964, The Four Fundamental Concepts of Psychoanalysis (with Lacan identifying these four concepts as the unconscious, repetition, the transference, and the drive). This seminar's opening session involved Lacan discussing his SFP-brokered “excommunication” from the IPA, with him comparing himself to Baruch Spinoza and the latter's expulsion from the Jewish community for being a heretic. However traumatic this blow, it seemed to prompt Lacan to come even more into his own, to forge a distinctly Lacanian battery of ideas and terms—and this by contrast with the more familiar Freudian language and apparatus of the first decade of le Séminaire (1953–1963). Although not without many precedents in his prior work, a Lacanianism distinct from Freudianism began to emerge clearly into view in the mid-1960s. In the shadow of his rejection by the IPA and departure from the SFP, Lacan founded his own analytic organization, the École freudienne de Paris. This new institutional framework (and freedom) provided him with a setting in which to experiment with novel approaches to analytic teaching and training.

Wednesday, April 10, 2013

Despite efforts by law enforcement and public health officials to curb prescription drug abuse, drug-related deaths in the United States have continued to rise, the latest data show.

Figures from the U.S. Centers for Disease Control and Prevention reveal that drug fatalities increased 3% in 2010, the most recent year for which complete data are available. Preliminary data for 2011 indicate the trend has continued.

The figures reflect all drug deaths, but the increase was propelled largely by prescription painkillers such as OxyContin and Vicodin, according to just-released analyses by CDC researchers.

The numbers were a disappointment for public health officials, who had expressed hope that educational and enforcement programs would stem the rise in fatal overdoses.

“While most things are getting better in the health world, this isn’t,” CDC director Tom Frieden said in an interview. “It’s a big problem, and it’s getting worse.”

Drugs overtook traffic accidents as a cause of death in the country in 2009, and the gap has continued to widen. (Italics and color added).

I’ve already written about my experience with Nic, but for my new book, Clean, I wanted to understand why so many suffer and die. So I undertook an investigation of the treatment system that so often fails. I learned that no one actually knows how often treatment works, but an oft-quoted number of those who abstain from using for a year after rehab is 30%. Even that figure is probably high. “The therapeutic community claims a 30% success rate, but they only count people who complete the program,” according to Joseph A. Califano Jr., the founder of the National Center on Addiction and Substance Abuse and former U.S. Secretary of Health, Education, and Welfare. “Seventy to eighty percent drop out in three to six months.” Over the course of my research, I did hear one statistic that I trusted. Father John Hardin, chair of board of trustees at St Anthony’s, a social services foundation with an addiction recovery program in San Francisco, told me, “Success for us is that a person hasn’t died.”

The treatment system fails because it’s rooted in an entrenched but inaccurate view that addicts are morally bereft and weak. If they weren’t, the belief goes, they’d stop using when drugs begin to negatively impact their lives. Most treatment centers in America are based on an archaic philosophy that’s rooted in the Twelve-Step model of recovery. Twelve-Step programs have saved countless lives, but they don’t work for a majority of people who try them. It’s not a fault in the program itself. Its founder, Bill Wilson, wrote, “These are but suggestions.” But many rehabs require them. This is particularly problematic for teenagers and young adults, the very people most susceptible to addiction. Twelve-Step programs require people to accept their powerlessness and turn their lives over to God or another higher power. Many adolescents question religion and in general teenagers aren’t going to turn their lives over to anyone.

In many of these Twelve-Step-based programs, patients are berated and yelled at if they don’t “surrender” and practice the steps. They’re warned — in some cases, threatened — that if they don’t they’ll relapse and die. It can become a self-fulfilling prophecy.

Tuesday, April 9, 2013

By Becca AaronsonThe Texas Tribune/The New York Times
Originally published March 31, 2013

Texas lawmakers have grappled year after year over whether families or medical professionals should decide when to end a terminally ill patient’s life-sustaining care. This year, they seem closer to a compromise.

“If we were only making decisions based on medical facts, everything would be straightforward,” said Dr. Leigh Fredholm, the medical director of Seton palliative care at the University Medical Center Brackenridge in Austin. “But that’s not how we make decisions.” (Seton is a corporate sponsor of The Texas Tribune.)

State law allows physicians to discontinue treatment they deem medically futile. If a physician’s decision to end treatment contradicts the patient’s advance directive or the judgment of the patient’s surrogates, state law gives patients or their families 10 days to find another provider and appeal the doctor’s decision to a hospital ethics committee.

Advocacy groups that identify as “pro-life” say existing law does not go far enough to protect the interests of patients or their families. But they are divided on how legislators should change it. While support in the Legislature’s upper chamber seems to be coalescing around Senate Bill 303, which would tweak the process, some support bills that would bar doctors or hospital ethics committees from making the final decision to end treatment.

Beverley Broadbent was not dying of a terminal illness, nor was she depressed or unhappy. But at 83, she wanted to die.

After living a rich and satisfying life, the Brighton East woman said the ageing process had come to feel like a disease that was robbing her of her physical and mental fitness. In February, she said she had had enough.

''I look well and I walk well so people think I'm fine. But I have so many things wrong with me,'' she said. ''The balance is gone. It's taking so much time for me to keep fit to enjoy myself that there's not enough time to enjoy myself.''

In several interviews with Fairfax Media, Ms Broadbent said she planned to take her own life so she could have a peaceful, dignified death. She said she did not want her health to deteriorate to the point where she had dementia or found herself in a nursing home with no way out.

Monday, April 8, 2013

A new study conducted by The Mind Research Network in Albuquerque, N.M., shows that neuroimaging data can predict the likelihood of whether a criminal will reoffend following release from prison.

The paper, which is to be published in the Proceedings of the National Academy of Sciences, studied impulsive and antisocial behavior and centered on the anterior cingulate cortex (ACC), a portion of the brain that deals with regulating behavior and impulsivity.

The study demonstrated that inmates with relatively low anterior cingulate activity were twice as likely to reoffend than inmates with high-brain activity in this region.

"These findings have incredibly significant ramifications for the future of how our society deals with criminal justice and offenders," said Dr. Kent A. Kiehl, who was senior author on the study and is director of mobile imaging at MRN and an associate professor of psychology at the University of New Mexico.

By JOHN MARKOFF and JAMES GORMANThe New York Times
Published: April 2, 2013

President Obama on Tuesday will announce a broad new research initiative, starting with $100 million in 2014, to invent and refine new technologies to understand the human brain, senior administration officials said Monday.

A senior administration scientist compared the new initiative to the Human Genome Project, in that it is directed at a problem that has seemed insoluble up to now: the recording and mapping of brain circuits in action in an effort to “show how millions of brain cells interact.”

It is different, however, in that it has, as yet, no clearly defined goals or endpoint. Coming up with those goals will be up to the scientists involved and may take more than year.

The effort will require the development of new tools not yet available to neuroscientists and, eventually, perhaps lead to progress in treating diseases like Alzheimer’s and epilepsy and traumatic brain injury. It will involve both government agencies and private institutions.

Sunday, April 7, 2013

By Deborah BrauserMedscape Medical News
Originally published March 14, 2013

Once again, psychiatrists top the updated Dollars for Docs list of large payments from pharmaceutical companies to individual US clinicians.

On March 12, the investigative journalism group ProPublica released the names of the 22 physicians who, since 2009, received more than $500,000 from these companies in speaking and consulting fees. Mirroring the organization's first report released in 2010, psychiatrists dominate the list.

This time, the top recipient was Jon Draud, MD, medical director of the psychiatric and addiction medicine program at Baptist Hospital in Nashville, Tennessee, and from the Middle Tennessee Medical Center in Murfreesboro.

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APA Reaction

"My immediate, honest response was that this boggles the mind," James Scully, MD, CEO of the American Psychiatric Association (APA), told Medscape Medical News.The entire story is here.

By Steven MintzEthics Sage Blog
Originally published on February 12, 2013

Last week I read an article on the failure of ethics education of business students to change the dynamic in the business world where the pursuit of self-interests trumps all else. We certainly have been through a decade or so of glaring unethical business practices at companies such as Enron and WorldCom, Bernie Madoff’s insider-trading scandal, and the financial meltdown of 2008-2010 from which we still have not recovered.

As a professor who teaches ethics I was struck by the reasoning given for the failure of ethics education. Some claim ethics is taught only in a separate course rather than integrated throughout the curriculum creating a perception in the minds of students that ethics is only important tangentially rather than as an integral part of business practice. I agree with this perspective but realize, having been an academic administrator for many years, the problem lies in not being able to get faculty from various business disciplines on board to incorporate ethics into their individual courses. Some feel unequipped to do so; others do not believe we should be “preaching” to college students.

I did some research on how ethics is taught to business students and their perspectives on business responsibilities and found some interesting results. Surveys conducted by the Aspen Institute, a think tank, show that about 60% of new M.B.A. students’ view maximizing shareholder value as the primary responsibility of a company; that number rises to 69% by the time they reach the program's midpoint.

There is nothing wrong with maximizing shareholder value – it is a basic tenet of capitalism. The problem lies when that is the only driver of corporate behavior to the exclusion of broader stakeholder approaches that would include customers, suppliers, and employees in the mix. Though maximizing shareholder returns isn't a bad goal in itself, focusing on that at the expense of societal interests can lead corporate decision-makers down the road of greed. By maximizing shareholder value, bonuses increase and stock options are worth more.

Saturday, April 6, 2013

By ALAN SCHWARZ and SARAH COHENThe New York Times
Published: March 31, 2013

Nearly one in five high school age boys in the United States and 11 percent of school-age children over all have received a medical diagnosis of attention deficit hyperactivity disorder, according to new data from the federal Centers for Disease Control and Prevention.

These rates reflect a marked rise over the last decade and could fuel growing concern among many doctors that the A.D.H.D. diagnosis and its medication are overused in American children.

The figures showed that an estimated 6.4 million children ages 4 through 17 had received an A.D.H.D. diagnosis at some point in their lives, a 16 percent increase since 2007 and a 41 percent rise in the past decade. About two-thirds of those with a current diagnosis receive prescriptions for stimulants like Ritalin or Adderall, which can drastically improve the lives of those with A.D.H.D. but can also lead to addiction, anxiety and occasionally psychosis.

“Those are astronomical numbers. I’m floored,” said Dr. William Graf, a pediatric neurologist in New Haven and a professor at the Yale School of Medicine. He added, “Mild symptoms are being diagnosed so readily, which goes well beyond the disorder and beyond the zone of ambiguity to pure enhancement of children who are otherwise healthy.”

By Harriet BrownThe New York Times
Originally posted on March 25, 2013

Mental-health care has come a long way since the remedy of choice was trepanation — drilling holes into the skull to release “evil spirits.” Over the last 30 years, treatments like cognitive-behavioral therapy, dialectical behavior therapy and family-based treatment have been shown effective for ailments ranging from anxiety and depression to post-traumatic stress disorder and eating disorders.

The trouble is, surprisingly few patients actually get these kinds of evidence-based treatments once they land on the couch — especially not cognitive behavioral therapy. In 2009, a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders. One survey of nearly 2,300 psychologists in the United States found that 69 percent used C.B.T. only part time or in combination with other therapies to treat depression and anxiety.

C.B.T. refers to a number of structured, directive types of psychotherapy that focus on the thoughts behind a patient’s feelings and that often include exposure therapy and other activities.
Instead, many patients are subjected to a kind of dim-sum approach — a little of this, a little of that, much of it derived more from the therapist’s biases and training than from the latest research findings. And even professionals who claim to use evidence-based treatments rarely do. The problem is called “therapist drift.”

Friday, April 5, 2013

By Robert WhitakerMad in America Blog
Originally published March 26, 2013

Martin Harrow and Thomas Jobe have a new article coming out in Schizophrenia Bulletin that I wish would be read by everyone in our society with an interest in mental health. Harrow and Jobe, who conducted the best study of long-term schizophrenia outcomes that has ever been done, do not present new data in this article, but rather discuss the central question raised by their research: Does long-term treatment of schizophrenia with antipsychotic medications facilitate recovery? Or does it hinder it?

This is a paper that needs to be widely known. I wish every psychiatrist in the country would read it, and I wish that it would be widely discussed in the media too.

Now, Harrow’s study produced findings that belied common wisdom. He and Jobe followed schizophrenia patients for 20 years, and those who got off antipsychotics, as a group, had much better outcomes. Over the long term, they were much more likely to be recovered, much more likely to work; they were much less likely to be experiencing psychotic symptoms; and they had better cognitive function and they were much less anxious. So how can you square that finding with research showing that when patients are withdrawn from antipsychotic medications, they relapse at a much higher rate? That is the evidence for long-term use of antipsychotics, and here is what Harrow and Jobe write: “We view the results from these discontinuation studies as involving a paradox.”

Within six to 10 months following discontinuation, they write, 25% to 55% of schizophrenia patients withdrawn from their medications relapse. But, they note, “relapse rates are considerably lower subsequently in discontinued schizophrenia patients who remain stable during these 6-10 months,” and that “patients with schizophrenia not on antipsychotics for a prolonged period do not show this tendency to relapse when they remain unmedicated.”

So the puzzle is this: Why is there such a high relapse rate in the immediate months following withdrawal, compared to the relapse rate when patients “remain unmedicated” after this initial discontinuation period?

Thursday, April 4, 2013

California's Department of Managed Health Care (DMHC) has cited Kaiser Permanente for using a deceptive dual record-keeping system to cover up violations of the state's "timely access" law, which restricts the amount of time mental health patients should have to wait for an appointment, as well as for other violations.

In a report filed last month, the DMHC concludes that many Kaiser mental health patients faced extensive waiting periods for appointments, well beyond the 10 days for a regular appointment that the law requires.

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Clinician Whistle-blowers

The violations were discovered through a standard survey or evaluation process that the DMHC uses to review compliance by all California health plans.

After the review was underway, complaints regarding timely access violations were brought forward by a group of Kaiser Permanente's own mental health clinicians, who were represented by the National Union of Healthcare Workers (NUHW). Those complaints were considered and incorporated in the evaluation, Rouillard said.

Among the psychologists lodging complaints was Andris Skuja, PhD, who said the violations had been observed for years before the clinicians referred their concerns to the DMHC.

"Over a number of years, we tried many internal mechanisms with Kaiser to address some mounting concerns we had about the adequacy of treatment," Dr. Skuja told Medscape Medical News.

Giving residents less time on duty and more time to sleep was supposed to lead to fewer
medical errors. But the latest research shows that’s not the case. What’s going
on?

Since 2011, new regulations restricting the number of continuous hours
first-year residents spend on-call cut the time that trainees spend at the
hospital during a typical duty session from 24 hours to 16 hours. Excessively
long shifts, studies showed, were leading to fatigue and stress that
hampered not just the learning process, but the care these doctors provided to
patients.

And there were tragic examples of the high cost of this exhausting schedule.
In 1984, 18-year old Libby
Zion, who was admitted to a New York City hospital with a fever and
convulsions, was treated by residents who ordered opiates and restraints when
she became agitated and uncooperative. Busy overseeing other patients, the
residents didn’t evaluate Zion again until hours later, by which time her fever
has soared to 107 degrees and she went into cardiac arrest, and died. The case
highlighted the enormous pressures on doctors-in-training, and the need for
reform in the way residents were taught. In 1987, a New York state commission
limited the number of hours that doctors could train in the hospital to 80 each
week, which was less than the 100 hour a week shifts with 36 hour “call” times
that were the norm at the time. In 2003, the Accreditation Council
for Graduate Medical Education followed suit with rules for all programs that
mandated that trainees could work no more than 24 consecutive
hours.

Wednesday, April 3, 2013

A new British study out in the journal PLOS ONE is stirring up a lot of debate, as it gives some estimates on the number of doctors who are giving patients placebo to treat their various conditions. It finds that a resounding 97% of the 783 doctors surveyed admitted to giving patients some sort of placebo in their practice. But it would be misleading to say that doctors are giving patients sugar pills or saline injections at the drop of a hat – there are different kinds of placebos, and, as the survey found, doctors have different feelings about when each should be used. Not surprisingly, so does the public.

“Pure” placebos are indeed sugar pills or saline injections with no therapeutic value (aside from that stemming from the psychological effects – more on this later). This “pure” variety was used by about 12% of the general practitioners at some time in their careers. Among these doctors, there were various motivations, including the wish to generate psychological treatment effects, to calm patients, to appease patients’ wish for a treatment, and to treat “non-specific complaints.” Half the doctors only told their patients something vaguely promising, like “this therapy has helped many other patients.” About 25% told their patients that the treatment “promoted self-healing,” and less than 10% revealed that the treatment was actually placebo.

“Impure” placebos, on the other hand, are therapies for which there is no strong evidence that they work for a given problem – for instance, the use of antibiotics to treat a virus, off-label uses of medications, or probiotics for diarrhea. Impure placebos also include lab tests or physical exams that are given simply in order to reassure patients. This type of placebo was much more common, with 97% of doctors reporting their use at least once across their career, and 77% reporting “frequent” use, i.e., at least once per week.